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SIMPLE,  COMFORTABLE 

AND  HUMANE  TREATMENT 

OF  FRACTURES 


Copyright,  1915 

BY 

R.   DE  PUY 


I 


PRICE  $1.00 


'RDloi 


THE  primary  treatment  of  practically  all  frac- 
tures is  rest,  and  the  rest  applied  to  the  parts 
immediately  involved  consists  in  immobiliza- 
tion. Repair  processes  in  bones  are  slow  because  of 
the  density  and  poor  blood  supply  of  osseous  tissue 
and  the  necessity  of  complete  anatomical  union  with 
calcified  material  before  functional  use  can  become 
normal.  To  meet  this  indication  of  rest  necessary 
for  repair,  splints  of  many  types  have  been  used  suc- 
cessfully since  history  recorded  injuries.  Wood,  iron, 
leather,  stiff  cardboard,  and  more  especially  plaster  of 
Paris,  have  met  the  demands  of  the  medical  profes- 
sion until  recently.  Side  excursions  have  been  made 
into  silicates  and  other  quickly  hardening  substances 
which  can  be  applied  to  fit  the  contour  of  different 
parts  of  the  human  body,  and  they  have  all  fallen  into 
disuse  on  account  of  expense  or  trouble  of  application. 
There  remained  to  be  devised  material  which  would 
be  pliable  enough  to  permit  moulding  to  fit  different 
contours  and  sizes  of  limbs,  and  which  would  also 
possess  sufficient  property  of  stiffness  and  firmness  to 
furnish  support  for  fractured  extremities.  Plaster 
of  Paris  used  as  circular  casts  has  the  disadvantage  of 
being  dangerous  from  the   standpoint   of  swelling  of 


FRACTURES 


the  parts  within,  of  absorbing  discharges,  and  of  be- 
coming dirty  and  foul  in  a  short  time.  When  used 
as  moulded  splints  some  of  these  objections  fail. 
However,  moulded  splints  can  be  used  on  but  one 
patient;  they  crack  and  become  worn  out  in.  a  short 
time  and,  in  common  with  all  plaster  of  Paris  dress- 
ings, need  assistance  for  application.  This  applica- 
tion must  be  performed  within  a  limited  time  —  it 
is  mussy  and  expensive,  and  plaster  is  not  always  to 
be  obtained  in  fresh  condition  which  permits  a  solid, 
non-crumbling  setting. 

The  De  Puy  Adjustable  Wire  Splints  have  been 
manufactured  to  avoid  many  of  these  drawbacks. 
They  are  light,  pliable  enough  to  permit  moulding, 
can  be  used  over  and  over  again,  and  allow  ready 
inspection  of  the  limb  without  removal.  There  is  no 
fear  of  compression  or  of  interference  with  circulation 
and  subsequent  malpractice  suits.  Ambulatory  pa- 
tients find  them  comfortable  and  not  a  burden. 

Compound  fractures  can  be  held  in  position  easily, 
and  discharges  cause  no  damage  to  the  splint,  which  is 
covered  with  a  non-oxidizable  and  non-rusting  mixture. 
These  splints  can  be  attached  by  adhesive  or  bandag- 
ing, as  the  surface  is  rough  enough  to  prevent  slipping. 
Their  advantages  are  summed  up  as  — 

1.  Lighter,  cooler,  and  cleaner,  with  better  wear- 
ing qualities  than  any  other  type  of  splint. 

2.  They  will  last  for  years  and  care  for  many  cases, 
being  especially  valuable  for  hospital  use. 

3.  They  are  adaptable  to  all  fractures  of  the 
extremities. 


FRACTURES   OF   THE    CLAVICLE 


5 


4.  They  are  not  entirely  "ready  made"  splints, 
but  are  applied  by  moulding  and  bending  and  in  com- 
bination to  fit  each  patient. 

5.  They  are  cheaper  than  any  other  satisfactory 
splint  and  are  used  by  the  most  advanced  teachers 
of  fracture  treatment. 

6.  They  permit  X-ray  exposure  and  picture-tak- 
ing without  removal  and  consequent  pain  and  distress 
to  the  patient. 

FRACTURES    OF   THE   CLAVICLE 

The  usual  site  is  the  junction  of  the  middle  and 
outer  thirds,  and  the  bracing  or  stay-like  action  of  the 
bone  holding  the  shoulder  out  is  lost.     The  shoulder 


Fig.  1 

Hawes'  Clavicle  Splint  in  2  Sizes,  Nos.  47  and  48 

Shoulder  Cap  Not  Shown 

tends  to  fall  forward,  downward,  and  inward  when 
this  support  is  lacking,  and  the  clavicle  itself  takes 
on  an  apparent  deformity.  As  it  lies  just  beneath  the 
skin,  crepitus  and  deformity  are  easily  ascertained. 


FRACTURES 


The  clavicular  portion  of  the  insertion  of  the  sterno- 
cleidomastoid muscle,  meeting  with  no  opposition 
when  the  continuity  of  the  bone  is  lost,  tends  to  pull 
upward  the  inner  fragment,  the  outer  fragment  falling 
downward,  dragged  bv  the  shoulder  weight.  (See 
Fig.  1.) 


Fig.  2 
Front  View  Showing  Hawes'  Clavicle  Splint  Applied 

Reduction  consists  in  replacing  the  fragments  in 
their  normal  position.  This  is  aided  by  pressure  on 
the  fragments  and  by  raising  the  shoulder  upward, 
outward,  and  backward  from  its  deformed  position 
overcorrecting  until  the  injured  shoulder  is  held  on  a 
higher  level  than  the  sound  side.  (See  Fig.  2.)  Hawes' 
clavicle  splints  Nos.  47  and  48  fulfill  these  requirements 


FRx\CTURES   OF   THE   CLAVICLE 


and  hold  the  forearm  and  hand  in  a  comfortable  posi- 
tion, which  is  instantly  adjusted,  without  removing 
the  whole  dressing,  simply  by  tightening  or  loosening 
the  straps.  The  arm  on  the  injured  side  is  bandaged 
with  one  layer  of  cotton  sheet  wadding,  and  the 
shoulder  cap  with  the  strap  retainer  is  placed  on  the 
sound    shoulder    over    light    padding.     (See    Fig.    3.) 


Fig.  3 
Back  View  Showing  Hawes'  Clavicle  Splint  Applied 

Beneath  the  arm  on  the  injured  side  is  placed  angular 
elbow  splint  No.  17  or  18,  lightly  padded,  which  acts 
as  an  axillary  support  to  hold  the  shoulder  out  from 
the  chest.  Free  circulation  of  air  is  permitted  through 
the  wire  meshes  and  there  is  no  opportunity  for  skin 


FRACTURES 


maceration  from  sweating.  (See  Fig.  3.)  This  is 
fastened  to  the  chest  wall  by  a  broad  piece  of  adhesive 
tape  passing  through  it  onto  the  body.  The  arm 
portion  of  the  splint  is  then  slipped  on  after  making 
sure  that  there  is  no  pressure  over  the  pointy  of  the 


Fig.  4 

Angular  Elbow  Splints  Nos.  17,  18,  70.     Shaped  to  be  Used  as 

Wedge  in  Axilla  Space 

elbow,  and  the  straps  are  tightened  to  the  desired 
position  of  overcorrection.  If  the  splint  is  narrow 
for  an  unusually  large  forearm,  it  can  be  bent  or 
moulded  wider  to  fit.  It  should  be  noted  that  the 
elbow  point  is  made  very  full  to  avoid  pressure.     Ad- 


FRACTURES   OF   THE   HUMERUS 


justments  of  arm  elevation  can  be  made  easily  and 
quickly  by  the  straps.  After  three  weeks  in  the 
splint,  when  callus  appears  in  the  clavicle,  the  arm  can 
be  removed  daily  by  light  passive  movements  of  the 
shoulder  and  elbow.  General  massage  is  also  indicated. 
After  the  fourth  week  the  splint  is  seldom  used. 

This  same  dressing  can  be  used  after  reduction  of 
shoulder  dislocations,  being  worn  for  from  ten  to 
fourteen  days.  Its  advantages  are  obvious:  the 
position  obtained  is  highly  satisfactory  and  easily 
readjusted;  the  site  of  the  fracture  is  open  for  inspec- 
tion or  manipulation;  there  is  no  adhesive  plaster 
dressing  to  cut  or  macerate  the  skin  on  the  arm,  and 
the  forearm  and  hand  are  held  in  a  comfortable,  steady 
position. 

FRACTURES   OF   THE   HUMERUS 

For  the  sake  of  convenience  these  are  divided  into — 

a.  Fractures  of  the  head,  tuberosity,  and  neck. 

b.  Fractures  of  the  shaft. 

c.  Fractures  of  the  condyles  and  at  the  elbow. 

a.  Fractures  of  the  head,  tuberosity,  and  neck. 
Fractures  of  the  head  itself  are  rare  and  often  accom- 
pany dislocation,  as  do  also  fractures  of  the  tuberosity. 
Usually  the  injury  of  the  head  is  a  crack  or  split,  and 
the  indication  for  treatment  consists  in  rest  to  permit 
the  joint  effusion  to  subside,  followed  by  passive  mo- 
tion when  pain  is  not  caused. 

After  dislocation  of  the  shoulder,  fractures  of  the 
tuberosity  are  diagnosed  by  skiagram  and,  rarely, 
by    palpation    or    loss    of    function.      The    broken-off 


10 


FRACTURES 


fragment  is  pulled  backward  and  upward  by  the 
spinati  muscles,  and  treatment  must  be  directed  toward 
bringing  the  shaft  out  into  contact  with  the  shell 
pulled  off.  This  is  accomplished  by  a  position  of  ab- 
duction and  outward  rotation  of  the  arm. 


Fig.  5 
Shoulder  Splints  Nos.  24,  25,  26 

Fractures  of  the  surgical  neck  are  common  and  may 
be  impacted.  The  usual  displacement  is  to  find  the 
head  rotated  outward  and  abducted,  the  shaft  frag- 
ment being  pulled  inward  and  upward  by  the  pectoral 
muscles.  Reduction  is  made  by  extension  on  the 
arm,  manipulation  of  the  fragments  into  line,  and 
their  maintenance  by  splints  (see  Fig.  5)  Nos.  24, 
25,    26,    applied    over   the    lightly    padded    shoulder, 


FRACTURES   OF   THE    IIIMERI  S 


11 


aided  by  splints  (see  Fig.  6)  Nos.  17,  18,  in  the  axillary 
space,  or  (see  Fig.  7)  Nos.  21,  22,  23,  on  the  inner  side 
of  the  arm,  high  up.  These  splints  are  snugly  bound  on 
and  the  forearm  supported  by  a  sling,  either  in  splint 
(see  Fig.  8)  No.  19,  20,  or  42,  or  used  in  combination 
with    the    others.      Abduction    is    furnished    by    the 


Fig.  6 
Angular  Elbow 

Splints 
Nos.  17,  18,  70 


axillary  splint  No.  17  or  18.  (See  Fig.  4.)  This 
treatment  applies  to  all  fractures  in  this  area,  including 
the  rim  of  the  glenoid  and  neck  of  the  scapula. 

b.     Fractures  of  the  shaft  are  transverse,  oblique,  or 


12 


FRACTURES 


Fig.  7 

Humerus  Splints 

Nos.  21,  22,  23 


spiral,  the  displacement  varying  with  the  location. 
When  fracture  is  below  the  insertion  of  the  deltoid  mus- 
cle the  upper  fragment  is  pulled  outward  and  upward; 
if  the  break  is  above  this  insertion,  the  lower  frag- 
ment is  pulled  upward  and  outward.  The  position 
of  fragments  is  usually  apparent  from  the  deformity, 
and  treatment  is  indicated  to  bring  them  into  align- 
ment and  hold  them  there.  The  fragments  are 
gently  manipulated  into  place, 
the  line  of  the  longitudinal  arm 
axis  is  straightened,  and  two 
large  humerus  splints,  Nos.  21 
and  22,  are   bandaged   on   over 


Fig.  8 
Elbow  Splints, 

Posterior, 
Nos.  19,  20,  42 


FRAC^TURES   OF   THE   HUMERUS 


13 


the  padded  arm.  The  forearm  is  supported  in  a  sHng 
or,  better,  by  combination  with  elbow  spHnt  No.  19, 
20,  or  42.  (See  Fig.  9.)  If  the  overriding  is  trouble- 
some and  difficult  to  correct,  as  in  oblique  and  spiral 
fractures,  splints  Nos.  71  or  72,  which  have  been  devised 
to  make  extension  on  the  humerus,  should  be  used. 
The  forearm   piece   of  this   splint,   after  being  firmly 


Fig.  9 
Showing  Complete  Immobilization  of  Arm  with  Splints 
Nos.  24,  21,  19,  1 

strapped  on,  gives  counter-extension  from  the  saddle 
piece  which  goes  into  the  padded  axilla.  (See  Fig.  10.) 
Several  inches  of  extension  is  provided  for  by  the 
threaded  bar  or  crutch  which  supports  the  axillary  piece, 


14 


FRACTURES 


The  nut  is  turned  up  until  sufficient  extension  pressure 
is  obtained  and  this  is  held  bv  the  second  lock-nut. 

The  rod  supporting  the  axillary  band  is  fastened  by 
a  swivel  so  that  the  patient  can  rotate  the  arm  out- 
ward at  will  without  danger  of  disturbing  the  position 


Fig.  10 

Humerus  Extension 

Splints 

Nos.  71,  72 


of  the  fragments.  Adjustment  of  extension  is  easily 
made  by  the  nuts  without  removing  the  splint,  w^hich 
may  be  held  on  by  the  straps  alone  or  by  a  light  roller 
bandage  applied  over  all.  (See  Fig.  10.)  Sphnts 
Nos.  71  or  72  are  also  indicated  in  fractures  low  down 
on  the  shaft  which  do  not  extend  into  the  elbow  area 


FRACTURES   OF   THE   HUMERUS  15 

and  which  demand  extension  to  hold  proper  position. 
Humerus  spHnts  Nos.  21,  22,  23,  or  posterior  elbow 
splints  Nos.  19,  20,  42,  can  be  used  in  combination. 
(See  Fig.  9.)  For  the  -complete  immobilization  of 
the  arm  in  a  right-angled  position  a  combination  of 
splints  Nos.  1,  73,  19,  21,  and  24,  by  telescoping  one 
part  into  the  other,  fulfills  all  requirements  of  arms  of 
varying  sizes. 


Fig.  11 
Acute  Angle  Elbow  Splints  Nos.  76,  77,  78 

c.  Fractures  of  the  condyles  and  at  the  elboiv.  Supra- 
condylar fractures,  or  those  which  involve  the  elbow 
joint,  including  T  fractures,  usually  have  a  posterior 
displacement  of  the  lower  fragments.  When  either 
condyle  alone  is  broken  off,  it  tends  to  be  displaced 
laterally  and  upward.  The  indication  for  treatment 
is  to  replace  the  fragments  in  the  best  possible  position 


16 


FRACTURES 


and  to  avoid  a  stiffness  in  the  elbow  joint.  Author- 
ities now  agree  that  the  best  position  in  many  eases 
is  one  of  acute  flexion;  that  is,  with  the  forearm  flexed 
well  onto  the  arm  and  held  there  until  bony  union 
is  started.  This  flexion  should  be  enough  to  make 
the  angle  between  arm  and  forearm  less  than  60  de- 
grees. It  is  maintained  for  two  weeks  by  splint  No. 
76,  77,  or  78,  which  can  be  removed  frequently  for 
massage  if  the  forearm  is  held  in  its  flexed  position  and 
not  allowed  to  move.  (See  Fig.  11.)  After  two  weeks 
the  elbow  joint  is  moved  a  little  and  the  splint  can  be 
bent  to  a  greater  angle  to  allow  the  forearm  to  extend 
gradually.  After  the  third  week  the  arm  can  be 
lowered  to  a  right  angle  and  splint  No.  73,  74,  or  75, 
or  No.  19,  20,  or  42,  can  be  worn  for  a  couple  of  weeks 
with  daily  massage  and  passive  motion.  This  type 
of  splint  aims  to  maintain  the 
carrying  angle  by  holding  the 
forearm  and  arm  in  the  same 
axis,  a  most  important  factor  in 
the  treatment.     (See  Fig.  12.) 


Fig.  12 

Right  Angle 

Elbow 

Splints, 

Anterior, 

Nos.  73, 

74,  75 


FRACTURES   OF   THE   FOREARM  17 

FRACTURES   OF   THE   FOREARM 

a.  Fractures  of  the  olecranon.  The  displacement  is 
practically  always  a  pulling  upward  of  the  proximal 
fragment  by  contraction  of  the  triceps  muscle.  The 
indication  for  treatment  is  to  reduce  the  swelling  and 
to  try  to  get  the  fragments  in  apposition.  This  can 
be  done  by  full  extension  of  the  forearm,  which  brings 
the   shaft   of  the   ulna  nearlv   into   contact   with  the 


Fig.  13 

Angular  Elbow  Splints  Nos.  17,  18,  70,  Used  Straight  for 

Fracture  of  Forearm 

detached  fragment,  which  can  rise  no  higher  than  the 
limit  allowed  by  the  olecranon  fossa  of  the  humerus. 
Splint  No.  17,  18,  or  70,  which  permits  adjustment,  is 
the  proper  one  to  use.  This  is  applied  over  the  padded 
arm  on  the  anterior  side,  with  the  arm  at  first  in  full 
extension.  (See  Fig.  13.)  Every  second  day  it  is 
removed  for  massage  and  after  two  weeks  light  move- 
ments of  passive  flexion  are  started  and  the  angle  of 
the  splint  is  gradually  lessened.  Four  weeks  should 
give  good  union.  A  long  coaptation  splint  may  be 
substituted  for  the  elbow  splint. 


18 


FRACTURES 


b.  Fractures  of  the  upper  end  and  head  of  the  radius 
are  best  treated  with  the  forearm  in  flexion,  after 
reckiction.  The  forearm  should  be  held  in  supination, 
turned  over  on  its  back,  in  splints  used  for  the  elbow 
fracture,  Xos.  76,  77,  78,  and  19,  ^20,  or  42,  ete.  (See 
Figs.  11  and  8.) 

c.  Fractures  of  the  shaft  of  one  or  both  bones.  The 
shaft  of  the  ulna  is  straight  and  palpable  in  its  whole 
length.  The  radius  is  curved  and  rotates  around  the 
ulna.     Consequently  when  the  shaft  of  one  or  both 


Fig.  14 
Radius  Splints  Nos.  1,  2,  3,  4,  5,  6.     (Three  Sizes  in  Rights  and  Leftsj 

bones  is  broken,  the  indication  is  to  correct  the 
deformity  and  displacement  by  manipulation  and 
traction  on  the  hand,  and  then  hold  the  bones  as  far 
apart  as  they  can  be  separated  while  heahng. 

The  best  position  for  this  is  supination.  This 
separates  the  bones  and,  as  experience  shows  that  the 
restriction  of  use  after  forearm  fractures  is  nearly 
always  a  restriction  of  supination,  this  position  should 
be  chosen.  Splints  Xos.  1,  ^2,  3,  4,  5,  6,  7,  8,  43,  and 
44  can  be  used  alone  or  in  combination  with  the  coapta- 


FRACTURES   OF    IIIF    FC)RFAR:\I 


Fig.  15 
Forearm  and  Hand  Splints  Nos.  7,  8,  43,  44.     (Two  Sizes  in  Rights  and  Lefts) 

tion  splint  No.  63,  with  the  hand  turned  on  its  back. 
Sphnt  No.  19,  20,  or  42  can  be  used  in  connection. 
Sphnts  Nos.  1,  2,  3,  4,  5,  6,  7,  8,  43,  44,  or  a  coaptation 
splint  on  the  palmar  side  of  the  forearm.  (See  Figs. 
14,  15,  16.) 

d.  Fractures  of  the  lower  end  of  one  or  both  hones, 
and  Colles'  fracture.  In  Colles'  fracture  there  is  a 
typical   displacement   of   the   fragments.     There   is   a 


Fig.  16 

Coaptation  Splints,  10  Pieces,  5  to  10  Inches  in  Length, 

Two  of  Each  Size 

riding  upward  and  backward  of  the  lower  fragment, 
which  may  also  be  impacted  or  displaced  laterally. 
The  usual  appearance  is  a  hump  caused  by  this  frag- 


20 


FRACTURES 


nieiit  on  the  back  of  the  wrist,  the  so-called  "silver- 
fork  deformity."  The  first  indication  is  to  reduce 
this    deformity    and    displacement    by    unlocking    the 


Fig.  17 
Showing  an  Example  of  Radius  Splints  Nos.  1,  2,  3,  4,  5,  6,  Applied 

fragments  and  shoving  the  lower  one  down  into  place. 
With  the  deformity  overcome,  the  hand  and  the  fore- 
arm rest  very  comfortably  in  splint  Nos.  1,  2,  3,  4,  5,  6, 


FRACTURES   OF   THE    FOREARM 


21 


T 


Fig.  18 
Showing  Colles'  Splints  Applied 

or  Nos.  45,  46,  which  is  strapped  on.  This  leaves  the 
fingers  uncovered  and  free  to  move  as  they  must  from 
the  first.  (See  Figs.  17,  18,  and  19.)  After  ten  days 
the  sphnt  is  removed  daily  for  massage  and  move- 
ments, and  after  the  third  week  it  can  be  dispensed 
with  altogether.  Both  bone  fractures  near  the  wrist 
are  treated  similarly  after  reduction  by  traction  and 
manipulation.  Fractures  of  the  wrist  and  metacarpal 
bones  have  little  displacement  and  usually  heal  satis- 
factorily   if    given    sufficient    immobilization.     If    im- 


Fig.  19 
Colles'  Splints  Nos.  45  and  46.     (Posterior  Part  Not  Shown) 


22 


FRACTURES 


paired  wrist  motion  is  feared,  or  an  ankylosis  threatens 
for  any  reason,  the  hand  is  best  put  in  a  position  of 
shght  extension,  above  the  straight  Hne  of  the  forearm, 
because  this  preserves  the  gripping  power.  Sphnts 
Xos.  7,  8,  43,  and  44  are  used  by  the  surgeon  with 
padding  to  fit  the  angle  of  fixation  he  may  desire. 
They  are  left  on  three  or  four  w^eeks.  Do  not  be  in 
a  hurry  to  start  movement  after  carpal  fractures. 


Fig.  20 
Finger  Splints  Nos.  49  and  50 

Fractures  of  the  carpal  bones  are  treated  best  by 
putting  the  hand  in  flexion.  The  Colles'  splints  Nos. 
45  and  46,  or  Xos.  1,  2,  3,  4,  5,  and  6,  which  permit  the 
hand  to  be  bandaged  in  flexion  around  the  end,  an- 
swer this  purpose.     They  are  left  on  about  three  weeks. 

Fractures  of  the  fingers  are  treated  by  the  finger 
splint  adjusted  to  any  degree  of  flexion  (Nos.  49  and 
50).  This  can  be  moulded  to  any  degree  of  flexion 
by  bending  and  fitting  to  the  well  hand  before  appli- 
cation. Any  angulation  desired  can  be  secured,  de- 
pending on  the  position  which  holds  the  reduced  frag- 
ments best.  The  long  forearm  piece  is  bandaged  or 
strapped  on  and  the  finger  is  then  fixed  to  the  distal 


FRACTURES   OF   THE   FEMUR  23 

portion  of  the  splint.     Two  to  three  weeks'  wear  is 
snfficient  for  union.      (See  Figs.  20  and  21.) 

FRACTURES  OF  THE  FEAIUR 

a.  Fractures  of  the  neck  and  head  usually  involve 
a  shortening  of  the  leg  from  one  to  three  inches.  The 
foot  is  rotated  outward  and  cannot  be  lifted  by  the 
patient;  and  the  trochanter,  palpable  beneath  the  skin, 


Fig.  21 
Showing  Finger  Splint  Applied 

is  found  elevated  above  Nealton's  line,  drawn  from 
the  anterior  superior  iliac  spine  to  the  ischial  tuber- 
osity. The  indication  for  treatment  is  to  bring  the 
broken  shaft  into  line  with  the  head  fragment.  This 
is  done  by  extension,  elevation,  and  abduction  and  is 
accomplished  by  splint  No.  65  or  66.  (See  Fig.  22.) 
This  is  a  strong,  durable  splint,  which  must  be  used  on 
a  fracture  bed;  i.e.,  one  which  is  supported  by  boards 
placed  across  the  bed  beneath  the  mattress  to  prevent 
sagging.     Both   the   thigh   and   leg   segments   of   this 


24 


I RACTURES 


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FRACTrRK-    OF    TIIK    KHMTR 


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Fig.  23 
Showing  CombinaTion  Leg  Splint  Applied  for  Buck's  Extension 

splint  are  adju>tcO)le  for  different  sized  individuals  or 
t()  all()w  for  padding. 

The  gutter  may  he  widened  hy  bending  out  the 
frame  and  the  angle  of  inelination  is  ehanged  easily 
l)y  the  setscrew.  which  locks  firmly  at  the  base.  The 
heel  of  the  footpiece  is  made  large  to  avoid  pressure, 
and  through  the  slitlike  openings  at  the  foot  the  straps 
of  a  Buck's  extension  can  l:)e  passed  to  be  attached  to 
a  Aveight  at  the  foot  oi  the  bed.       See  Fig.  ^23.^ 

By  means  of  the  rings  along  the  upper  border  of 
the  splint  the  whole  leg  can  be  swung  up  by  attach- 


Fig.  24 
Showing  Combination  Leg  Splint  Applied  for  Hodgen's  Suspension 


26 


FRACTURES 


Fig.  25 
Showing  One-Half  of  Femur  Splints  Nos.  67,  68,  69 


Fig.  26 
Showing  Femur  Splint  Applied 


FRACTURES   OF   TIIF    1  KMIR 


Zi 


ment  to  a  longitudinal  bar  built  above  the  l)e(l.     This 
gives  an  adjustable  Hodgen's  splint.      (See  Fig.  24.) 

For  fracture  of  the  neck  of  the  femur  this  splint  is 
used  in  slight  angulation  with  or  without  Buck's 
extension  and  in  a  position  of  abduction.  It  is  diffi- 
cult to  obtain  abduction  unless  two  splints  are  used. 


Fig.  27 
Anterior  Patella  Splints  Nos.  34  and  35 

One  is  applied  to  each  leg,  and  both  are  fastened  in 
place  on  the  bed  by  a  crossbar  at  the  foot  end,  or  held 
apart  by  a  wooden  bar  notched  at  each  extremity  or 
with  an  adjustable  rod  which  we  can  supply  for  that 
purpose. 

h.  Fractures  of  the  shaft,  from  just  below  the  tro- 
chanters to  near  the  knee  are  transverse,  spiral,  or  com- 
minuted; and  if  the  fracture  is  below  the  attachment 
of  the  psoas  to  the  lesser  trochanter,  the  upper  frag- 
ment is  usually  flexed.  Consequently  the  indication 
is  to  flex  the  thigh  and  apply  some  extension  to  over- 
come shortening.  The  reduction  of  fragments  can 
be  made  and  splints  Nos.  67,  68,  or  69  can  be  strapped 
on  as  coaptation  splints  (see  Figs.  25  and  26),  and  then 


28 


FRACTURES 


HllflgHIII^""""''-'"^^^'^'^'^"^"^^^ 


Fig.  28 
Posterior  Patella  Splints  Nos.  36,  37,  38 

the  whole  leg  is  placed  in  splint  No.  ^b  or  ^^  at  the 
angle  of  elevation  desired.  The  same  modifications 
and  use  as  a  swinging  Hodgen's  splint  can  be  used  as 
described  under  ''Fractures  of  the  Neck  of  the  Femur." 
(See  Fig.  24.)  Large  coaptation  splints  can  also  be 
used  to  help  steady  the  leg. 

Femur  splints  Nos.  67,  68,  or  69  may  be  used  in 
combination  with  anterior  patella  splints  Nos.  34  and 
35,  and  posterior  patella  splints  Nos.  36  and  38  to 
immobilize  the  thigh  and  knee  joint.  (See  Figs.  27,  28, 
29,  and  30.) 


Fig.  29 

Showing  Anterior  and  Posterior  Patella  Splints  Applied  in  Combination 

with  Utility  Splint  No.  39,  40,  or  41 


FRACTURES   OF   THE    FKMIR 


Splints  Nos.  67,  68,  or  ()9  have  also  been  used  for 
immobilization  of  the  chest  in  ril)  fractures.  (See 
Fig.  25.)  The  chest  is  lightly  padded,  and  adhesive 
straps  are  passed  around  the  outside  of  the  splint, 
which  is  opened  and  laid  on  the  padding.  The  ad- 
hesive should  pass  beyond  the  middle  line  both  at  the 


Fig.  30 
Utility  Splints  Nos.  39,  40,  41 

back  and  front  and  be  anchored  to  the  bare  skin.     The 
chest  should  not  be  completely  encircled,  of  course. 
c.     Fractures  of  the  lotver  end  and  condyles  of  the 


30 


FRACTURES 


femur,  knee-joint  fractures,  and  fractures  of  the  upper 
end  of  the  tibia.  Those  involving  the  lower  end  of  the 
femur  usually  have  a  displacement  of  the  lower  frag- 
ment backward,  pulled  by  the  gastrocnemius  muscle. 
The  indication  is  to  hold  the  leg  in  part  flexion  to  bring 
the  shaft  and  lower  fragment  in  line.     This  is  accom- 


Fig.  31 
Showing  Immobilization  of  Leg  Using  Splints  Nos.  34,  36,  and  31 


plished  by  splints  No.  65  or  66  elevated  to  the  proper 
angle.  Fractures  into  the  knee-joint  and  the  upper 
end  of  the  tibia  are  treated  in  the  same  manner  with 
the  addition  of  Buck's  extension  to  separate  the  joint 
surface,  to  avoid  ankylosis,  and  correct  shortening. 
If  there  is  little  displacement  in  fractures  of  the  upper 
end  of  the  tibia,  they  can  be  treated  in  flat  extension 
with  or  without  Buck's  in  this  same  splint.  If  desired, 
Nos.  34  and  35  can  be  used  anteriorly  to  help  main- 
tain position. 


FRACTURES   OF   THE    HONKS   OF    IIIF    FKO       ;U 

FRACTURES   OF   THE    PATEELA 

This  bone  is  usually  pulled  apart  by  muscular  action, 
which  also  tears  the  joint  capsule.  The  upper  frag- 
ment is  pulled  up  by  the  quadriceps  extensor  and  the 
lower  fragment  is  held  by  the  patellar  ligament  at- 
tached to  the  tibia.  There  is  consequently  separation 
of  greater  or  less  extent,  and  the  indications  are  to 
cause  the  distention  of  the  joint  to  subside  and  to 
bring  the  fragments  into  apposition.  This  can  only 
be  done  by  holding  the  leg  in  complete  extension. 
Splints  Nos.  34  and  35,  combined  with  No.  36  or  38,  do 
this,  and  act  as  a  comfortable  support  until  the  patient 
is  transported  for  operation.      (See  Fig.  29.) 


Fig.  32 
Anterior  Tibia  and  Fibula  Splints  Nos.  29,  30,  64 

FRACTURES  OF  THE  BONE  OF  THE  LEG 

a.  One  or  both  bones  in  their  shafts  (knee-joint 
fractures  are  discussed  under  the  femur).  Shaft 
fractures  are  spiral,  transverse,  or  comminuted,  and 
the  fibula  is  usually  broken  higher  up  than  the  tibia. 


32 


FRACTURES 


There  is  shortening  and  generally  an  angular  dis- 
placement, especially  in  the  spiral  type.  The  indica- 
tion is  to  overcome  the  shortening  by  traction  and 
reduce  the  angular  displacement  at  the  site  of  fracture 
by  pressure  under  anaesthesia.     Splint  No.  31,  3'2,  or  33 


Fig.  33 

Posterior  Tibia  and  Fibula  Splints  Nos.  31,  32,  33. 

Used  Indifferently  Right  or  Left 

is  used  to  hold  the  reduction,  which  may  be  used  in 
combination  with  splint  No.  29,  30,  or  64.  In  some 
cases  of  nervous  or  alcoholic  patients  it  is  wise  to 
combine  also  No.  34  or  35  and  No.  36  or  38  with 
them.  Coaptation  splints  over  a  badly  displaced 
fibula  or  a  persistent  deformity  in  the  tibia  are  also 
a  good  combination.     (See  Figs.  31  and  32.) 

b.  Fractures  at  the  loiver  end,  the  two  malleoli,  and 
Pott's  fracture.  When  both  bones  are  broken  above 
the  ankle,  the  axis  of  the  leg  must  be  perfected  and  the 
foot  held  at  a  right  angle  to  the  leg  and  in  alignment 
with  its  long  axis  regardless  of  the  displacement  after 


FRACTURES  OF  THE  BONES  OF  THE  LE(.  :v.\ 


Fig.  34 

Pott's  Fracture  Splints  Nos.  79,  80,  81,  82. 

Used  Indifferently  Right  or  Left 


34 


FRACTURES 


Fig.  35 

Showing  Pott's  Fracture  Splint  Applied 

(Notice  Flexible  Hinge  at  Ankle) 

the  break.  This  is  accomphshed  by  sphnt  No.  31,  32, 
or  33,  alone  or  in  combination  with  anterior  tibia 
and  fibula  splint  No.  29,  30,  or  64.  (See  Figs.  32 
and  33.)  The  Pott's  fracture  splint,  which  is  adjust- 
able, can  also  be  used. 

For  fractures  of  the  malleoli,  internal  or  external 
malleolus,  both  malleoli.  Pott's  fracture,  the  Pott's 
fracture  splint  No.  79,  80,  81,  and  82  have  been  devised. 
(See  Fig.  34.) 


FRACTURES  OF  THE  BONES  OF  THE  LE(i 


')•) 


Fractures  of  the  internal  malleolus  alone  call  for 
immobilization  of  the  foot  in  a  line  with  the  long  axis 
of  the  leg  and  at  right  angles.  Posterior  displacement 
should  be  guarded  against  by  padding  the  heel  well 
forward.     These  fractures  are  rare. 


Fig.  36 
Showing  Pott's 
Fracture  Splint 

Applied 


Fractures  of  the  external  malleolus  alone,  with  or 
without  slight  injury  of  the  internal  malleolus  and 
rupture  of  the  internal  lateral  ligaments,  is  what  is 
understood  by  the  term  "Pott's  fracture."  In  this 
the  foot  is  usually  displaced  outward  by  the  twist, 
and    the    astragalus    is    pushed    outward.     Posterior 


36 


FRACTURES 


displacement  also  may  be  present.  The  indication  is 
to  bring  the  foot  well  forward  and  swing  it  inward  by 
pressing  against  the  internal  malleolus  until  the  astrag- 
alus is  shoved  back  into  position  beneath  the  tibia. 
(See  Figs.  35  and  36.)     The  foot  is  thus  inverted  and 


Fig.  37 
Pott's  Fracture  Splint  Applied 

adducted;  it  must  also  be  held  at  right  angles  to  the 
long  leg  axis.  This  adjustable  splint  No.  79,  80,  81, 
or  8^2,  fastened  to  the  leg  above,  is  swung  into  the 
position  desired  and  the  thumb-nuts,  which  main- 
tain the  position  of  overcorrection  in  adduction,  are 
tightened.  This  should  be  left  on  four  weeks,  with 
removal  for  massage.  No  weight  is  borne  for  from 
six  to  eight  weeks. 

For  fractures  of  both  malleoli  the  indications  for 
treatment  depend  on  the  displacement.  If  there  is 
much  posterior  displacement,  it  must  be  corrected 
by  padding  the  foot  well  forward.  Lateral  displace- 
ment of  the  foot  is  also  corrected  by  manipulation. 


FRACTURES   OF   THE   JAW    HONE 


.>/ 


Fig.  38 
Maxilla  Splints  Nos.  27  and  28 


Fig.  39 
Showing  Maxilla  Splint  Applied 


38  FRACTURES 


and  the  foot  is  usually  placed  in  a  position  of  slight 
abduction  by  tightening  the  thumb -nuts  when  the 
position  is  secured.  If  it  is  desired,  the  footpiece 
can  be  changed  to  hold  the  foot  in  slight  plantar  or 
dorsal  extension.  x\  bandage  may  be  applied  over 
all,  or  if  the  splint  is  left  open  there  is  room  for  the 
application  of  an  ice  bag. 

For  ankle  and  foot  fractures  the  Pott's  splint  No. 
79,  80,  81,  or  82  is  the  best,  as  it  permits  the  foot  to 
be  held  in  any  desired  position  of  flexion,  extension, 
abduction,  or  adduction  after  reduction  is  finished. 
(See  Fig.  37.) 

The  Pott's  fracture  splint  for  children  is  also  avail- 
able for  permanent  dressing  to  hold  club-foot  in  chil- 
dren after  reduction  by  manipulation  or  tenotomy. 
The  lightness  and  cleanliness  of  this  splint,  together 
with  its  durability  and  ease  of  adjustment  to  any 
desired  angle,  make  it  a  favorite  for  club-foot. 

AS  A  POST-OPERATIVE   DRESSING 

Any  combination  of  the  previously  described  splints 
can  be  used  after  open  operation  for  the  application 
of  Lane  plates  or  bone-splints.  The  wire  mesh  per- 
mits instantaneous  inspection  of  the  limb  and  short- 
ens and  simplifies  post-operative  dressing.  Stitches 
can  be  removed  and  massage  administered  with 
little  trouble  to  the  patient. 

DE  PUY  MANUFACTURING  CO. 

CORNER  MARKET  AND  COLUMBIA  STREETS 
WARSAW,  INDIANA 


R.   R.   DONNELLEY  &  SONS  CO.,  CHICAGO 


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